Caring for Illegals, Losing Their Shirts: The effect of the wave on border- state medical services.

Jim McNeal remembers the night like it was yesterday. "We got a call at about 11 o'clock saying there'd been a bad accident -- a van had crashed out in the middle of nowhere, and it was stuffed with 26 illegal aliens from Mexico." McNeal's company, Schaefer Ambulance Service, handles 911 calls in California's rural Imperial County, right on the border. Three of his vehicles raced to the scene on Highway 78, west of the Salton Sea. "Six of the passengers were dead on the spot, and two weren't harmed. We provided immediate treatment to the 18 others and rushed them off to hospitals."

That was a year and a half ago. Since then, McNeal hasn't seen a dime for his efforts. "We weren't paid for what we did, and we won't ever be paid," he says. His company, in fact, has written off more than $620,000 over the last six years for uncompensated services provided to illegal aliens. "I don't understand why I have to bear this expense," says McNeal. "Border control is supposed to be a federal problem, not a Schaefer Ambulance problem. It's just not fair." But it's also typical. Schaefer Ambulance makes up a very small piece of a very large problem. In 2000, hospitals and emergency-service providers lost more than $200 million because they weren't reimbursed for treatment given to illegal aliens, according to a study sponsored by the United States/Mexico Border Counties Coalition. Individual physicians may have lost another $100 million. That's because federal law requires emergency rooms to accept all comers, regardless of their citizenship or their ability to pay for services. Hospitals already take a beating from malpractice litigation, Medicaid reimbursement schemes, and uninsured patients -- it's a tough business to be in just about anywhere. Those near the border, however, must cope with the added complication of illegal-alien freeloaders. Many area hospitals are being forced to cut back services or to close their doors entirely, which means that out-of-control immigration has become not only an inconvenience for millions of Americans, but a public-health hazard.

If the 24 counties touching Mexico formed a 51st state, stretching from Brownsville in south Texas all the way to San Diego, it would be the poorest in the country and the one with the highest level of unemployment: Household incomes are about $10,000 lower than the national average and the jobless rate is more than 12 percent. This is the area through which illegal aliens must travel if they enter the United States from Mexico by car or on foot. Many of them take great risks to sneak across the border, making them prone to injury. Jumping walls leads to broken bones, crossing deserts courts dehydration, and jamming a couple dozen people into a van invites the kind of disaster McNeal found in Imperial County. As a result, the aliens find themselves crowding border hospitals and forcing the have- not locals to pick up the tab.

The Border Patrol is supposed to keep illegal aliens out of the country, but its agents actually worsen the problem. Officers are experts at rounding up crossers and persuading them to leave the country without filing phony asylum claims and the like. When they apprehend people who need immediate medical attention, however, they rush them to the hospital without formally taking them into custody. This is humane on one level -- if people need the urgent attention of doctors, they should get it without first having to endure an interrogation. But it's also an act of bureaucratic self-interest. If the Border Patrol were actually to arrest injured aliens, it would have to assume responsibility for the cost of their care. So instead it picks them up in the wilderness and drops them off at emergency rooms -- and never bothers to check back. The hospitals are stuck with the bills. When the aliens' treatment is finished, they're released into the community and are free to go where they please.

Sometimes customs officials on the border will even admit Mexican ambulances on "compassionate entry" grounds in the belief that an injury is so bad, the victim will suffer irreparable harm if he doesn't receive the immediate attention of American doctors. This happened hundreds of times in Douglas, Ariz., last year. Cassy Salmon, a nurse in Douglas, even thinks her Mexican counterparts take advantage of the U.S. mandatory-care laws. "They lie to us," she says. "If they have a patient who can't pay his bills, they will say he needs more help than they can provide and put him on an ambulance for Arizona."

Which isn't to say the injuries are never legitimate. If a factory worker in Agua Prieta loses a limb in an accident, for instance, there's nothing nearby on the Mexican side of the border that can help.

But the tiny hospital in Douglas isn't equipped to save his life, either. The closest trauma center is in Tucson, and that's where he'll go for treatment. In part because of costs like this, the Tucson Medical Center is about to unplug its trauma unit. The only other trauma center in the city is also in serious trouble: The University Medical Center expects to lose about $5 million this year because of foreign nationals, up from $4 million last year. "I'm $2 million in the hole right now, so that's the difference between running at a profit or a loss," says John Duval, the chief operating officer. "Systems fracture at their stress points. For us, foreign nationals are a stress point."

Doctors everywhere face lawsuits, driving up the costs of what they do. This problem, too, is made worse on the border. "If a guy is shot in Mexico, he'll go to the hospital over there and start to crater in two or three days," says Antonio Falcon, a family practitioner in Rio Grande. "By the time he's a total mess, they'll send him over here and he'll die because we didn't see him early enough. Then everybody on our side of the border gets sued."

Most medical litigation is not really about malpractice, but about outcomes -- if somebody dies in a hospital, there's always a lawyer willing to make a case out of it. A few years ago, Falcon helped treat a Mexican man with a perforated colon. "He was in septic shock," says Falcon. "The surgeon saved his life." Yet it was a difficult recovery, and the patient had to receive extensive follow-up treatment. Falcon and his colleagues at Starr County Memorial Hospital were sued. "The case was dismissed, but for three years I had to go through the time, trouble, and expense of defending myself for helping this guy live longer," says Falcon. "This scenario plays out over and over down here."

The cost problem isn't confined to border counties, either. Jesica Santillan -- whose case recently drew national attention after Duke University botched her organ transplant -- was an illegal alien from Mexico. As much as we must sympathize with her plight, we might also note that her family entered the United States without visas for the express purpose of receiving medical care.

The best solution, of course, is for Mexico to improve its health-care system, but this will take time. A short-term solution would be to increase federal reimbursements. Local hospitals and clinics face huge financial burdens because the federal government has failed in its duty to police the border. Washington already reimburses some costs -- but only about $25 million per year, which doesn't even begin to address the magnitude of the problem. "I've never seen any of these reimbursements," says McNeal of Schaeffer Ambulance. A new bill sponsored by Republican senator Jon Kyl (Ariz.) would increase this annual allotment to $1.4 billion.

There's something to be said for this approach, given that so many hospitals are in dire financial straits. "People are dying because of this problem," Kyl points out. But at the same time, immigration reformers should beware. Here is a growing constituency of people along the border fed up with immigration policy. They're already becoming mobilized politically, but they're seeking a payoff rather than a fundamental reform. As a doctor might say, they're trying to treat a symptom, rather than the disease itself.